Health Care
Medical (2009)
Verifying Coverage for a Procedure/Treatment
When to Call
It is strongly recommended if you are having a costly procedure
or a procedure of which you or your provider are unsure of coverage (which is not on the list)
that you still call the pre-certification number on your ID card to verify coverage. By calling, you can verify that
the procedure is both a covered benefit and it is determined by the plan to be
medically necessary, thereby reducing the possibility of being left with large
unpaid medical bills.
These conditions include but are not limited to:
Durable medical equipment with cost of purchase or rental more than $1,000
Infertility treatments
Medical injectables (often may be obtained through Caremark’s prescription drug benefit)
Within 48 hours after receiving urgent or emergency care out-of-network to confirm coverage
-
Uvulopalatopharyngoplasty (surgery to the uvula or soft palate usually done for sleep apnea),
including laser-assisted procedures and sleep studies
Any surgical procedures involving the jaw or cutting of the jawbone
Reconstructive procedures and procedures that may be considered cosmetic such as:
Excision of excessive skin due to weight loss
Rhinoplasty/rhytidectomy (nose surgery/face lift)
Gastroplasty/gastric bypass (plastic surgery abdomen/weight reduction surgery)
Pectus excavatum repair (breast bone repair)
Blepharoplasty/canthopexy/canthoplasty (eyelid surgeries)
-
Breast reconstruction/breast enlargement
Breast reduction/mammoplasty (reshaping breast)
Surgical treatment of gynecomastia (male breast)
Lipectomy or excess fat removal
Treatment of penile dysfunction
Sclerotherapy or surgery for varicose veins
Any other potentially cosmetic procedure
Any procedure that may be considered experimental or not yet proven effective
Any extensive out-of-network care, to determine if charges will be
within reasonable and customary levels.
Any time you are uncertain of coverage.
What Information Do You Need?
To get a pre-determination, you will need the following information:
Medical CPT-4 or procedure code of the services to be performed
Doctor’s name, telephone number and tax ID number
Doctor’s proposed billing of the procedure, if out-of-network.
To verify coverage, the insurance carrier may ask you and/or
your doctor to complete a form with more information. Please allow at least five to
10 business days, if possible, to complete the process.
Also consider …
Pre-Certification of Medical Benefits